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3 PEAKS CHALLENGE REGISTRATION FORM

IMPORTANT: Teams must be made up of a minimum of 3 and a maximum of 5 “climbers”.
The maximum number of team members allowed is 6. Please give full home addresses
for every team member and enter your driver’s details in the “team member 6” box.

All field marked with are mandatory.
AFC Event Name :
Team Name:
Captain Title:
Captain Forename:
Captain Surname:
Date of Birth: eg DD/MM/YYYY
Captain Address1:
Captain Address2:
Captain Town:
Captain County:
Captain Postcode:
Captain Email Address: Please take care of spaces while adding email address.
Captain Main Tel:
Captain Home Tel:
Captain Work Tel:
Captain Mobile:
Captain Job Title:
Captain Employer:
Captain Employer Address:
T-Shirt Size S / M / L / XL / XXL:
How did you hear about this event ?:
 
Team Member2 Title:
Team Member2 forename:
Team Member2 surname:
Date of Birth:: eg DD/MM/YYYY
Team Member2 Address1:
Team Member2 Address2:
Team Member2 Town:
Team Member2 County:
Team Member2 Postcode:
Team Member2 Email: Please take care of spaces while adding email address
Team Member2 Home tel:
Team Member2 work tel:
Team Member2 Mobile:
Team Member2 Job Title:
Team Member2 Employers name:
Team Member2 Employer Address:
T-Shirt Size S / M / L / XL / XXL:
 
Team Member3 Title:
Team Member3 forename:
Team Member3 surname:
Date of Birth: eg DD/MM/YYYY
Team Member3 Address1:
Team Member3 Address2:
Team Member3 Town:
Team Member3 County:
Team Member3 Postcode:
Team Member3 Email: Please take care of spaces while adding email address
Team Member3 Home tel:
Team Member3 work tel:
Team Member3 Mobile:
Team Member3 Job Title:
Team Member3 Employers name:
Team Member3 Employer address:
T-Shirt Size S / M / L / XL / XXL:
 
Team Member4 Title:
Team Member4 forename:
Team Member4 surname:
Date of Birth: eg DD/MM/YYYY
Team Member4 Address1:
Team Member4 Address2:
Team Member4 Town:
Team Member4 County:
Team Member4 Postcode:
Team Member4 Email:
Team Member4 Hometel:
Team Member4 work tel:
Team Member4 Mobile:
Team Member4 Job Title:
Team Member4 Employers name:
Team Member4 Employer address:
T-Shirt Size S / M / L / XL / XXL:
 
Team Member5 Title:
Team Member5 forename:
Team Member5 surname:
Team Member5 DOB: eg DD/MM/YYYY
Team Member5 Address1:
Team Member5 Address2:
Team Member5 Town:
Team Member5 County:
Team Member5 Postcode:
Team Member5 Email: Please take care of spaces while adding email address
Team Member5 Home tel:
Team Member5 work tel:
Team Member5 Mobile:
Team Member5 Job Title:
Team Member5 Employers name:
Team Member5 Employer address:
T-Shirt Size S / M / L / XL / XXL:
 
Team Member6 Title:
Team Member6 forename:
Team Member6 surname:
Date of Birth: eg DD/MM/YYYY

Please indicate whether this team member is a dedicated driver (recommended) or if they will be climbing with the team. Note: there is a maximum of five climbing members of a team.


Please specify:
DEDICATED DRIVER or DRIVER AND CLIMBER
Team Member6 address1:
Team Member6 address2:
Team Member6 Town:
Team Member6 County:
Team Member6 Postcode:
Team Member6 Email: Please take care of spaces while adding email address
Team Member6 Home Tel:
Team Member6 Work Tel:
Team Member6 Mobile:
Team Member6 Job Title:
Team Member6 Employer Name:
Team Member6 Employer Address:
T-Shirt Size S / M / L / XL / XXL:
NAME OF TEAM’S NOMINATED NAVIGATOR

PLEASE NOTE: Every team taking part in the 3 Peaks Challenge must have at least one team member who can navigate on a mountain using a map and compass. Please give the name of one person in your team who can do this or who will undertake basic instruction on how to do this prior to the event

:
Have you or any of your team members taken part in an
Action for Charity challenge before?

If yes, please give details:

Approximate time team anticipates completing the challenge in (in hours)

Action for Charity promises to respect your privacy. The information
you have provided will be used by Action for Charity and the charity
concerned for the purposes of administering the event. The data we
gather and hold is managed in accordance with the Data Protection
Act (1998) and will not be passed on to other organisations. We will
not disclose or share personal information supplied by you with any
third party without your consent.Action for Charity would however
like to contact you about future charity events.Please tick the box
below if you do not wish us to do that.

I do not wish my details to be passed to other event participants


We do not wish to be contacted about future Action for Charity events

We would like to apply for a team place for the 3 Peaks Challenge in aid of Action Medical Research and agree to abide by the Terms & Conditions. Our team pledges to raise a minimum of £2,000 for Action Medical Research.

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